JAN-FEB 2016

MedEsthetics—business education for medical practitioners—provides the latest noninvasive cosmetic procedures, treatment trends, product and equipment reviews, legal issues and medical aesthetics industry news.

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36 JANUARY/FEBRUARY 2016 | Med Esthetics dosage, which means it's purely anti-infl ammatory," says Dr. Lupo. Patients don't have to worry about developing a resistance, which makes it ideal for more severe cases where they need long-term oral medication. "Although it's approved for the papules and pustules of rosacea, anecdotally we do see some improvement in the redness of rosacea with Oracea," adds Dr. Berson. Oral antibiotics as well as topical cyclosporine emulsion may also be used in the case of ocular symptoms, says Dr. Harper. IN-OFFICE SUPPORT As part of her holistic approach to treating rosacea, Dr. Lupo actively discusses diet with her patients. Her anti- infl ammatory regimen includes omega 3 supplementation and a diet low in alcohol, carbohydrates and sugar. "More than any other condition, I see improvement in rosacea when patients improve their diets," says Dr. Lupo. Adjunctive in-offi ce treatments, such as salicylic acid peels, intense pulsed light (IPL) and laser procedures, may provide faster relief for rosacea patients as well. Salicylic acid, which is related to aspirin and therefore anti- infl ammatory, will certainly calm the papulopustular component and may also soothe redness. "I perform salicylic acid peels on rosacea patients who are red, ruddy or infl amed and maybe have some papules," says Dr. Berson. "It helps calm the skin, gives patients a 'glow' and may improve the appearance of their pores, while subtly improving tone and texture." For erythema and telangiectasia, Dr. Lupo will use IPL or the excel V (Cutera) 532nm laser, and Dr. Berson similarly offers VBeam Perfecta (Syneron Candela) treatments. "These lasers can target both the vessels and the redness. I typically use a 10mm spot size, from 7J to 7.5J and 10ms pulse width," says Dr. Berson. IPL and vascular lasers will offer quick relief, though it is temporary, notes Dr. Harper. She counsels her patients that they can conceal erythema and papules with makeup as well. Of note, dermatologists have been anecdotally noticing improvements in fl ushing when they inject neurotoxin into these patients. "There are increased neurotransmitters in patients with rosacea, therefore fl ushing may be another potential target for neuromodulators," says Dr. Berson. "Patients notice an improvement of their fl ushing and oiliness in areas injected. I wouldn't call it a treatment at this point—just an observation when we're injecting rosacea patients with neurotoxin." ONGOING RESEARCH Though there are a number of ways to calm and treat the symptoms of rosacea, the underlying cause is still unclear beyond the fact that it's an issue of chronic infl ammation. "It's a growing fi eld in terms of understanding what rosacea is and the best way to treat it," says Dr. Popkin. "So in some ways what we have in our tool box is relatively primitive, and it refl ects the absence of our knowledge. Even with a common topical like metronidazole—it's an antibiotic, but we don't really know how or why it's working." Dr. Popkin and his colleagues are currently studying the facial microbiomes of twins in which only one of them has rosacea. "We did swabs on the left and right cheeks of different twin pairs, and we then sequenced their microbiomes," he says. "Essentially we're trying to look for any type of correlation between the bacteria on their skin and the severity or absence of their rosacea." Their data is still being analyzed and this particular study has not yet been published. In August 2015, the Journal of the American Academy of Dermatology ( JAAD) published a study from Taiwan in which researchers found that dyslipidemia, coronary artery disease and hypertension were signifi cantly associated with rosacea. Coronary artery disease remained independently associated with rosacea after adjustment for hypertension, diabetes mellitus and dyslipidemia. Dr. Lupo has seen the link between cardiovascular disease and patients with rosacea and psoriasis for many years in her practice. She attributes it to infl ammation and it's why dietary supplements, particularly omega 3s, are standard protocol for her rosacea patients. "Omega 3s are very important for preventing cardiovascular disease, and I do see a link to cardiovascular disease in both rosacea and psoriasis," she says. "I think it's that pro- infl ammatory environment of the patient." Dr. Harper also points out that tetracycline antibiotics, such as Oracea, may help reduce cardiovascular risk in addition to easing rosacea symptoms. "Cardiovascular comorbidities are being reported in association with dermatologic conditions whose root cause involves infl ammation, including rosacea, psoriasis and possibly eczema," says Dr. Berson. "It will be interesting to see what we as dermatologists can do for our patients to improve their infl ammatory skin conditions and how this might have a potential positive impact on an underlying cardiac risk they might have had. I don't know that we know the answer yet, but it's certainly food for thought." Laura Beliz is the associate editor of MedEsthetics. CALMING THE STORM "Constricting the muscle lining of some of the bigger vessels will decrease redness by decreasing the blood fl ow."

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